Diabetes Patients on Medicare Advantage Plans May Not Receive Optimal Care

Adults aged ≥65 years with type 2 diabetes (T2D) enrolled in Medicare Advantage (Advantage) plans were more likely to receive preventive services such as smoking cessation, foot care, and routine screening but far less likely to be prescribed newer, more expensive diabetes medications, according to a study published Thursday in Diabetes Care.

The study authors, from the University of Pittsburgh School of Medicine, found that those on the Medicare Advantage plans also were more likely to have higher blood pressure and poorer control of blood glucose than patients on Medicare fee-for-service (FFS) plans.

Investigators, led by Utibe Essien, MD, MPH, assistant professor of medicine at the University of Pittsburgh and staff physician at the VA Pittsburgh Healthcare System, express concern that while the Medicare Advantage model aims to improve access to preventive care, their findings suggest the rapid rise in numbers of older adults enrolling in the plans could foreshadow a decline in health outcomes and disparities in care for these patients compared to their counterparts in FFS programs.

Essein emphasizes that preventive care doesn’t guarantee patients won’t need to use the health care system “down the road.” “We need to make sure the right patients are getting the right treatment, likely a combination of preventive and therapeutic interventions,” he added in a School of Medicine press release.

“We need to make sure the right patients are getting the right treatment, likely a combination of preventive and therapeutic interventions.”

For the retrospective cohort study, Essein and colleagues used data from patients seen by more than 5 000 clinician participants in the Diabetes Collaborative Registry. Eligible patients were aged ≥65 years, had T2D, were treated with ≥1 antihyperglycemic therapy, and were on either Medicare FFS or Advantage plans. Data used were from 2014 to 2019. 

The investigators compared quality metrics, control of cardiometabolic risk factors, and patterns of antihyperglycemic prescribing between the 2 Medicare plan groups, using multivariable regression to adjust for sociodemographic and clinical factors.

The final cohort numbered 345 911 Medicare beneficiaries of which 229 598 (66%) were enrolled in FFS and 116 313 (34%) in Advantage plans for ≥1 month.

Findings: Medicare disadvantage

Essein et al found that Advantage beneficiaries were more likely than FFS enrollees to receive ACE inhibitors/angiotensin receptor blockers for coronary artery disease, tobacco cessation counseling, and screening for retinopathy, foot care, and kidney disease (adjusted P≤.001 for all). Patients in the Advantage group, however, had modestly but significantly higher systolic blood pressure (+0.2 mmHg), LDL cholesterol (+2.6 mg/dL), and HbA1c (+0.1%) (adjusted P<.01 for all) and were independently less likely than FFS recipients to receive glucagon-like peptide 1 receptor agonists (6.9% vs 9.0%; adjusted odds ratio [aOR] 0.80, 95% CI 0.77–0.84) and sodium–glucose cotransporter 2 inhibitors (5.4% vs 6.7%; aOR 0.91, 95% CI 0.87–0.95).

Essien said, "We saw a clear drop in Medicare Advantage enrollees getting those medications, despite unequivocal evidence that they benefit patients with diabetes by reducing kidney disease, cardiovascular disease and death."

Approximately 1 in 5 Medicare beneficiaries aged ≥65 years has diabetes, according to the press statement, and the disease is associated with out-of-pocket prescription costs more than 60% higher for these individuals vs those without diabetes.

"With Medicare Advantage plans continuing to rapidly expand and now covering nearly half of all Medicare beneficiaries, these data call for ongoing surveillance of long-term health outcomes under various Medicare plans," said senior author Muthiah Vaduganathan, MD, MPH, co-director of the Center for Implementation Science and staff cardiologist at Brigham and Women's Hospital and Harvard Medical School.

The researchers hope that these findings can help fine-tune the Medicare Advantage program, allowing patients to access the care and treatments they need while keeping costs and health care utilization low.

"Given the rising risk factors for diabetes among Americans, we're going to see increasing numbers of Medicare Advantage enrollees needing high-quality diabetes care," Essien said. "I'm a general internist – my primary focus is on prevention – but our data suggest that is not enough."

Essien UR, Tan Y, Figueroa JF, et al. Diabetes care among older adults enrolled in Medicare Advantage versus traditional Medicare fee for service plans: The Diabetes Collaborative Registry. Diabetes Care. 2022;45:1549-1557. https://doi.org/10.2337/dc21-1178